During an assessment, a client diagnosed with generalized anxiety disorder rates anxiety as 9/10 and states, “I have thought about suicide because nothing ever seems to work out for me.” Based on this information, which nursing diagnosis takes priority?

Hopelessness related to anxiety as evidenced by client’s stating, “Nothing ever seems to work out.”

Ineffective coping related to rating anxiety as 9/10 as evidenced by thoughts of suicide.

Anxiety related to thoughts about work as evidenced by rates anxiety 9/10.

Risk for suicide related to expressing thoughts of suicide.

Answer and Explanation

The Correct Answer is D

Risk for suicide is the most urgent concern when a client expresses suicidal ideation. Generalized anxiety disorder may elevate suicide risk, especially when compounded by hopelessness and impaired coping. According to DSM-5, suicidal thoughts in the context of anxiety signal acute distress and require immediate safety interventions. The priority in nursing care is always physiological safety, which aligns with Maslow’s hierarchy of needs—preserving life precedes addressing emotional or psychological concerns.

Rationale for correct answers

4. Risk for suicide is the priority diagnosis because the client has verbalized suicidal ideation. This poses an immediate threat to life and demands urgent intervention, including safety planning and continuous monitoring.

Rationale for incorrect answers

1. Hopelessness is present but secondary to the suicide risk. While the statement reflects despair, it does not override the need to address the client’s safety first.

2. Ineffective coping may contribute to suicidal ideation, but it is not the most critical concern. Coping strategies can be addressed after ensuring the client is safe.

3. Anxiety is evident, but it is not the priority when suicidal thoughts are expressed. The rating of 9/10 supports severity, but the suicide risk takes precedence.

Take Home Points

Suicide risk always takes priority in nursing diagnoses when ideation is present.
Generalized anxiety disorder can escalate to suicidal thoughts, especially when compounded by hopelessness.
Maslow’s hierarchy places physiological safety above emotional needs.
Nursing interventions must focus first on safety, then address underlying emotional and cognitive concerns.

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Correct Answer is B

Explanation

Benzodiazepinesare central nervous system depressants that enhance the effect of gamma-aminobutyric acid (GABA), producing sedative, anxiolytic, anticonvulsant, and muscle relaxant effects. They are indicated for short-termmanagement of anxiety, alcohol withdrawal, and procedural sedation. Long-term use is discouraged due to risks of dependence, tolerance, and cognitive impairment. Common side effects include drowsiness, confusion, and respiratory depression. Contraindications include sleep apnea, substance use disorders, and concurrent use with opioids or alcohol due to synergistic CNS depression.

Rationale for correct answers

2.Benzodiazepines are appropriate for short-term treatment of generalized anxiety disorder, alcohol withdrawal, and preoperative sedationdue to their rapid onset and calming effects. These uses align with their pharmacologic profile and safety guidelines for limited duration.

Rationale for incorrect answers

1.Long-term use for PTSD and convulsive disorders is discouraged due to risk of dependenceand tolerance. While benzodiazepines may be used acutely in alcohol withdrawal, chronic use is not recommended.

3.Benzodiazepines are not first-line for obsessive-compulsive disorder or essential hypertension. They may relieve muscle spasms but are not indicated for long-termmanagement of these conditions.

4.Long-term treatment of panic disorder and bipolar mania with benzodiazepines is not standard due to risk of addiction. Alcohol dependence requires structured withdrawal protocols, not maintenance benzodiazepine therapy.

Take Home Points

Benzodiazepines are best suited for short-term use in anxiety, alcohol withdrawal, and procedural sedation.
Long-term use increases risk of dependence, tolerance, and cognitive decline.
They are contraindicated in patients with substance use disorders or respiratory compromise.
SSRIs and other non-addictive agents are preferred for chronic anxiety and mood disorders.

A. Recognize the signs associated with an elevation in mood. B. Learn to obtain assistance when his anxiety is increasing. C. Develop guidelines for decreasing manipulative behavior of peers. D. Explore ways to facilitate participation in self-care activities.

Correct Answer is B

Explanation

Generalized anxiety disorder (GAD)is a chronic psychiatric condition marked by excessive, uncontrollable worry occurring more days than not for at least 6 months. It involves both psychological distressand somatic symptomssuch as restlessness, fatigue, and muscle tension. Management includes pharmacologic and non-pharmacologic interventions, with emphasis on early recognitionof symptom escalation and implementation of coping strategies to prevent functional impairment.

Rationale for correct answers

2.Learning to obtain assistance when anxiety increases reflects insight and self-monitoring, which are essential for relapse prevention. It promotes adaptive copingand timely intervention before symptoms escalate.

Rationale for incorrect answers

1.Recognizing signs of elevated mood is relevant to bipolar disorder, not GAD. GAD is characterized by persistent worry, not mood elevation or pressured speech.

3.Decreasing manipulative peer behavior is unrelated to GAD. This goal aligns more with personality disorders or conduct-related interventions.

4.Facilitating self-care participation is more applicable to depressive disordersor severe psychosis where motivation and functioning are impaired. GAD clients typically maintain self-care but struggle with excessive worry.

Take Home Points

GAD clients benefit from learning to recognize symptom escalation and seek support proactively.
Elevated mood and pressured speech are features of bipolar disorder, not GAD.
Goals should align with the client’s diagnosis and functional challenges specific to anxiety.
Self-care deficits are not primary in GAD unless comorbid depression is present.

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During an assessment, a client diagnosed with generalized anxiety disorder rates anxiety as 9/10 and states, “I have thought about suicide because nothing ever seems to work out for me.” Based on this information, which nursing diagnosis takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In which situation would benzodiazepines be prescribed appropriately?

Correct Answer is B

Explanation

After a nurse teaches a client with generalized anxiety disorder some strategies for coping with stressors, another goal for the client would be to:

Correct Answer is B

Explanation

A client diagnosed with generalized anxiety disorder has a nursing diagnosis of panic anxiety related to altered perceptions. Which of the following short-term outcomes is most appropriate for this client?

A client diagnosed with generalized anxiety disorder is placed on clonazepam (Klonopin) and buspirone (BuSpar). Which client statement indicates teaching has been effective?

A client with a history of generalized anxiety disorder enters the emergency department complaining of restlessness, irritability, and exhaustion. Vital signs are blood pressure 140/90 mm Hg, pulse 96, and respirations 20. Based on this assessed information, which assumption would be correct?

During an intake assessment, a client diagnosed with generalized anxiety disorder rates mood at 3/10, rates anxiety at 8/10, and states, “I’m thinking about suicide.” Which nursing intervention takes priority?

Which assessment information would be evaluated as objective data?

A nurse is caring for a client who has generalized anxiety disorder. Which statement about this client is true?

A nurse is admitting a client diagnosed with generalized anxiety disorder. During the client’s assessment, the nurse determines that which findings would be consistent with generalized anxiety disorder? Select all that apply.

Which client would the charge nurse assign to an agency nurse who is new to a psychiatric setting?